Depression and HIV associated neurocognitive disorders among HIV infected adults in rural southwestern Uganda: a cross-sectional quantitative study

Worldwide, the increasing access and use of HIV treatment has brought a dramatic change in the demographics of people living with HIV (PLWH) [1]. This has increased their longevity [2]. HIV infection targets the central nervous system in subcortical brain areas, causing brain impairment [3]. This increases the patients’ risk for various neurocognitive disorders such as HIV-Associated Neurocognitive Disorders (HAND) [4]. HAND is defined as impairment of multiple cognitive domains in association with HIV in the absence of other causes [5, 6]. Many factors, including age, gender, employment status and psychiatric disorders, have been associated with HAND. Among psychiatric disorders, depression is often more prevalent [7]. According to International statistical classification of diseases and related health problems (ICD) & Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), depression is defined as a mood disorder characterized by persistently low mood, a feeling of sadness and hopelessness and loss of interest in activities they once enjoyed [8, 9].

Several adverse outcomes are associated with depression such as failure to adhere to recommended medical care, diet, exercise, impaired functional status, reduced quality of life, increased morbidity and mortality [7, 10‐12]. However, insufficient attention has been paid to psychiatric conditions in HIV population in sub-Saharan Africa (SSA) notably in Uganda where most PLWH live and are in care [13].

Some studies in Zimbabwe and Kenya revealed that depression among PLWH is associated with poor health status, faster progression to AIDS and increased mortality [13, 14]. Furthermore, depression leads to reduced economic productivity and working abilities, social isolation and difficulties in problem solving [13]. According to Memiah, Shumba [15] and Wroe, Hedt-Gauthier [16], depression has been shown to predict non-adherence to ART.

A study by Nel and Kagee [17] in South Africa reported that non-adherent patients had a 3-fold higher risk of presenting moderate to severe depressive symptoms in comparison to adherent patients. The current study assessed the prevalence of depression and its association with HAND among HIV infected adults in rural southwestern Uganda.

Of the 393 that participated in the study, 105 (26.7%) were males and 288(73.3%) were females. The demographic characteristics of the participants are presented in Table 1 below:

The Chi square analysis showed that education level (χ2 (15) = 28.2 p = 0.02) and marital status (χ2 (15) = 28.7 p = 0.018) were associated with depression respectively. Religion, age and employment were not associated with depression. One way ANOVA revealed that the divorced were more associated with depression (F (6, 388) = 2.82, p = .0108). Similarly, participants with secondary (p = 0.018) and tertiary education level (p = 0.042) were more associated with depression compared to those without formal education.

Table 2 shows the depression classification of the participants who were living with HIV.

The results show that there is a statistical significant difference between the four classifications of depression (χ2 (3) = 9.63, p = 0.022). Majority (73.0%) of the participants had minimal depression and out of these, 22.4% were males and 50.6% females. The minority had moderate (0.3% males and 3.5% females) and severe depression (0.3% males and 0.5% females) respectively. The prevalence of depression was found to be 27%, higher in females (22.6%) than males (4.4%).

We aimed to assess the prevalence of depression and its association with HAND among people living with HIV in rural Southwestern Uganda. We found depression prevalence of: 73% minimal, 22.4% mild, 3.8 moderate and 0.8% severe. In these depressive episodes, the patient suffers from lowering of mood, reduction of energy, and decrease in activity. There is lack of concentration with marked tiredness and reduced capacity for enjoyment and interest in any activity. Sleep is usually disturbed and appetite diminished. Usually, there is absence of self-confidence and self-esteem even in the mild form.

While the mild depressive episode presents with two or three of the above symptoms, the patient is usually distressed but will be able to continue with most activities. The moderate depressive episode presents with four or more of the above symptoms, the patient is likely to have great difficulty in continuing with ordinary activities. With severe depressive episode, several of the above symptoms are marked and distressing, typically loss of self-esteem and ideas of worthlessness or guilt [8].

In our current study, the overall prevalence of depression was found to be 27%. It was more prevalent in females (22.6%) than males (4.4%) and much lower compared to the findings of Kagee and Martin [31] that estimated a prevalence of moderate and severe depression of 37.4 and 20%, respectively. The lower rates may be to the continued use of ART which has improved the health of PLWH. Similarly, studies conducted in Brazil reported a depression prevalence of 32–34% [32, 33] which shows a great association with neurocognitive loss. Though the prevalence of depression in the current study was lower than in other studies in South Africa and Brazil, it could not be neglected. The results suggest that a considerable proportion of PLWH may be experiencing psychiatric difficulty, for which they may not be receiving treatment. Clarke and Currie [34] also asserted that chronic conditions such as HIV are a major risk factor for depression more so in individuals that may be cognitively impaired. Multivariate logistic regression showed age between 44 and 50 (aOR 1.86, p value 0.023) and being a female was 2 times more likely to be associated with depression (aOR 2.01 P value 0.005). This may probably be due to women being more likely to suffer a greater number of stressful life experiences compared with men. This is in line with the study that reported the prevalence of major depression being higher in women (5.5%) than in men (3.2%) in 2010, representing a 1.7-fold greater incidence in women [35, 36]. Studies from developed countries suggest that the differential risk may primarily stem from biological sex differences where estrogen present may be protective in males [37].

With less efficient immune system, older patients receiving ART are at an increased risk of neuropsychological impairment such as depression [38]. With aging, PLWH experience more complications in the physiological and psychological domains of which little attention is given [39]. In sub-Saharan Africa, up to 25% of PLWH suffer from some of depression [40] and some studies indicate that older age is associated with depressive symptoms coupled with HAND [41] . A recent study has also reported a 24% increased risk of depression in older PLWH [42] and are more likely to develop viral resistance because of low level of ART adherence.

Conversely, HAND is on increase despite the era of effective antiretroviral therapy. In the present study, out of 393 participants, 58.3% screened positive for HAND. This is in consistency with other studies that used similar tools to screen for HAND [29, 43]. The associated factors were gender, peasant farming and older age. This agrees with Cross, Önen [10] who reported that socio-demographic factors such as age, gender, occupation, marital status might influence the likelihood of developing HAND.

We found a significant association between depression and HAND. Depression can lead to neurocognitive deficits indirectly through interference with medication adherence. This is different from other studies which reported that neurocognitive impairment and depression are independent complications of HIV [44, 45]. This might be attributed to the fact that most of the participants had advanced HIV disease due to delayed treatment initiation.

Despite the strong link between depression and HAND, it is striking that there is no attention given to depression in the routine HIV care yet it is a serious psychiatric comorbidity in PLWH. Even mild depression could have deleterious consequences on the lives of PLWH. It can lead to inconsistent adherence, poor care engagement and ultimately to more serious outcomes [42]. Screening for depression among these people should be an integral part of the HIV care package so that it is appropriately managed. The untreated mental disorders work against the successful treatment of PLWH which has a great impact on health outcomes that affect the quality of life. It would also be important to study depression and neurocognitive disorders more rigorously comparing the HIV+ and HIV- cohorts. These screening tools required extensive staff training and time to be administered which was a limitation because the study was conducted within the daily activities of routine HIV care.

We found that depression was strongly associated with HAND which greatly affects the functioning of an individual. Our findings point to the importance of early recognition of depression and HAND as they are associated with increased rates of poor drug adherence and other poor outcomes including increased risky behaviours.